Provider Demographics
NPI:1083269005
Name:ADVANCED FOOT AND ANKLE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ADVANCED FOOT AND ANKLE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:BALLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-674-0284
Mailing Address - Street 1:100 SIMSBURY RD STE 209
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3793
Mailing Address - Country:US
Mailing Address - Phone:860-674-0284
Mailing Address - Fax:860-674-0292
Practice Address - Street 1:100 SIMSBURY RD STE 209
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3793
Practice Address - Country:US
Practice Address - Phone:860-674-0284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-06
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000850OtherCONNECTICUT MEDICAL BOARD